How to plan great care for your renal patients in 5 simple steps
Tell me if this sounds familiar.
You get a crispy, azotaemic cat admitted for a few days of supportive care.
Their treatment looks a bit like this:
3 days of IV fluids
Tempting to eat, and some maropitant and mirtazipine
Repeat bloods at the end of the 3 days to see if things have improved.
Pretty common, right?
Well, in today’s post, I’m using my own cat - Nigel (if you’ve been here a while, you’ve probably met him a few times - he likes interrupting calls and IG videos!) - to show you just how much we can do with our renal patients.
I introduced him to my VIP list back in November as the final case in our Up Your Nursing Skills Challenge - and today, we’re going to explore the nursing care he’ll benefit from.
Let’s take a look at his case:
Meet Nigel
Nigel is an 11-year old MN DSH.
He has a history of lower urinary tract disease since he was 4, with recurrent calcium oxalate urolithiasis. He has chronic kidney disease following an AKI due to a previous ureteral obstruction, and unilateral SUB placement.
(Yes, he’s a nurses cat - what else did you expect?!)
His CKD has been stable (IRIS stage 2) for several years, but presents with a recent complaint of weight loss, weakness, halitosis, hyporexia and vomiting.
After examining him, we admit Nigel for diagnostics and management of either end-stage CKD, or acute-on-chronic kidney disease.
Examination
Nigel’s examination reveals
Marked weight loss (1kg in the past year; 22% of bodyweight)
Loss in muscle condition
Obvious muscle weakness and neck ventroflexion
Uremic breath
Dehydration (mild skin tenting and tacky MMs)
An expected tachycardia (160 beats/minute in a stressed patient) with a grade 2 heart murmur
An expected tachypnoea (60 breaths/minute in a stressed patient) with no abnormalities on auscultation
Normotension (BP 126mmHg systolic)
Initial Results
Nigel is cardiovascularly stable but dehydrated. We place an IV catheter and collect blood for a biochemistry panel, venous blood gas, haematology and total T4 level.
The vet then collects a urine sample via cystocentesis prior to starting IV fluids and performs an echo due to the heart murmur.
The results reveal:
Severe hypokalaemia (potassium 2.7mmol/L; normal 3.5-5.8)
Severe azotaemia (urea 40.7mmol/L; normal 5.3-10.7. creatinine 1200umol/L; normal 71-212)
Low USG (1010) without active sediment or infection
Metabolic acidosis (pH 7.2; bicarbonate and base excess low)
Structurally normal heart with no signs of cardiac disease
Non-regenerative, likely chronic anaemia (PCV 18%)
Nigel undergoes sedation for an abdominal ultrasound, which is consistent with advanced chronic kidney disease.
Nigel’s Treatment
Nigel begins supportive treatment to manage his suspected acute-on-chronic kidney disease, including:
IVFT with Lactated Ringer’s solution at 3ml/kg/hour
Potassium supplementation at 40mmol per litre of fluid
Maropitant (1mg/kg IV q 24 hours)
Mirtazapine (2mg/cat PO q 24 hours)
Repeat sampling for electrolytes and creatinine levels every 24 hours
Erythropoietin (darbepoetin) injection (1mcg/kg SC q 7 days depending on PCV)
Iron dextran (50mg/cat IM q 28 days)
Nigel’s creatinine level initially drops, but only to 1000umol/L. After a few days of supportive care, it has plateaued in the high 800s to low 900s. He initially eats, but his appetite declines in the hospital - despite being very happy in himself and showing no signs of nausea.
We elect to place an oesophagostomy feeding tube to provide long-term nutritional support, and create a feeding plan beginning at 1/3rd RER with a renal liquid diet.
Nigel remains in the hospital for 5 days, after which time he is discharged for ongoing care at home, including O tube feeds and subcutaneous fluids.
So what about Nigel’s nursing care?
So we’ve got Nigel admitted and settled, and started on his treatment plan. But what nursing interventions could we use to make him more comfortable in the hospital, and improve his care?
Nutritional Status and Appetite Support
Nutrition is going to be a BIG one in his case. We know he’s hyporexic and has lost over 20% of his bodyweight - and we know his worsened azotaemia is likely to be making him feel nauseous, so he’s unlikely to want to eat for himself.
Once we’ve got that O tube in place, and we’ll start by getting him on a gradual refeeding plan with a renal liquid diet, beginning at 1/3rd RER due to his hyporexia history.
And when he’s happily tolerating 1/3rd RER with no nausea or vomiting, we’ll increase to 2/3rds of his RER the following day, and aim to be meeting 100% of his RER on day 3 of feeding. I tend to start patients like him on feeds every 4 hours, just so we’re not giving too much food at any one time - but every 6 hours would also be fine, too. You can even do every 4 hours throughout the day, then skip a feed overnight to allow 8 hours of rest time. It’s all about balancing what works with your hospitalisation hours with your patient’s needs - there’s no hard and fast rules we must follow here.
Alongside tube feeding, we need to get Nigel eating for himself. I can tell you - he is not one to turn down food normally!
Once his nausea is controlled with maropitant, we can think about adding an appetite stimulant and start offering him food. Even though he’s being tube fed a renal diet, and has had renal diets before, I wouldn’t try him with one in the hospital - we want to make sure he’ll happily eat that diet long term, so instead, in the clinic we’ll tempt him with whatever he wants to eat.
The short term risks of worsening his azotaemia/phosphate by feeding an inappropriate diet in hospital are FAR outweighed by the benefits of him readily eating this for the rest of his life at home - so don’t worry too much about deviating from renal diets for these patients in the clinic!
Prior to each tube feed, we’ll offer Nigel the same number of calories he’d be due that feed in any food he prefers, and then measure how many calories he consumes. We’ll then top him up to his required amount with a partial tube feed as needed.
Hydration Status and Fluid Balance
Fluid balance is another really important consideration fo Nigel. He’s PUPD because of his kidney disease, has marked azotaemia (with an acute component to his renal disease) and is anorexic.
He’s going to need careful fluid therapy, - we want to reduce his azotaemia and support his kidneys, without pushing too much fluid and tipping him into volume overload.
We’ll weigh him twice daily and measure his urine output via weighing litter trays before and after use, estimating each 1g weight increase as 1ml of urine passed. That way, we can ensure we’re not significantly exceeding his urine output with our fluid therapy - and we can see quickly if his urine output is reducing.
If his urine output drops, we’ll need to also drop our fluid rate - as he’ll be at risk of fluid overload otherwise.
Nigel also has a heart murmur - and this is important for us to consider when making a fluid therapy plan. If he had structural cardiac disease, he’d be at an even higher risk of fluid overload - which is why we performed an echo in his case, to rule this out. Even if you don’t have capacity to do a full echo in your practice, doing a quick LA:Ao check in your murmur patients, and looking at vena cava size, can be helpful prior to administering fluids. This is absolutely a skill that nurses and technicians can learn to do!
We need to be monitoring not just Nigel’s weight and urine output - but also his hydration status at each clinical exam. Checking his skin tenting and MM tackiness or dryness will give us an indication of whether we’re correcting his dehydration appropriately. We can then adjust his fluid rate as needed once these parameters have improved.
The final thing to note with Nigels’ fluid therapy is his potassium level. Nigel is moderately hypokalaemic, causing his weakness. We’ll supplement his fluid therapy with potassium - 40mmol of KCl in every litre of fluid. This is about the limit of what we like to give through a standard peripheral IV, so we’re ok in that respect - but we need to be very careful about flushing that line, and we certainly don’t want to give any fluid boluses from this bag.
When anaesthetising Nigel for his O tube, or sedating him for his ultrasound, we’ll have a plain bag and line set up alongside his supplemented bag - that way, if we need to increase his rate or give him a fluid bolus, we’re not doing this with a supplemented bag, risking hyperkalaemia.
Eliminations
Managing urination and defecation is another important nursing consideration for Nigel. We’ve already discussed the importance of measuring his urine output, but what else do we need to think about?
Well, he’s got a history of lower urinary tract disease (he’s got a history of urethral obstructions and has previously had a perineal urethrostomy) - so making sure we’re using a deeply-filled tray with familiar cat litter in will be important for him.
We also know he’s polyuric, so regular tray checks are important - he’s far less likely to want to use a tray already soiled.
In terms of defecation, he’s dehydrated - and we know that dehydrated patients, especially CKD cats, often become constipated. So monitoring the frequency of defecation, and adding micralax or lactulose as needed, will also be an important nursing consideration for him. Noting ‘days since last defecated’ on the kennel sheet or the kennel door can be really helpful for patients like him, to ensure we’re not missing constipation between different nurses on shift each day.
Vascular Access and Sampling
Nigel will be having regular bloods to check his electrolytes and creatinine - he’s scheduled to have those daily initially. He’s also on IV fluids (with 40mmol/L potassium supplementation) and medications.
We could consider a PICC line in his case, since we could also use that to collect his samples and administer fluid therapy.
Nigel also has notoriously difficult veins, after years of 3-monthly sedations for SUB flushes, multiple surgeries, and regular samples. Getting a peripheral IV on him is not the easiest task - and if he was going to be in for a while, we might have to think about a central venous catheter should his legs not play ball.
A central venous catheter requires more intensive management from a nursing point of view - aseptic technique is an important consideration, along with twice daily site cleans and sterile dressing changes, regular flushing, and sample collection.
It’s also easy to inadvertently collect larger sample volumes via a PICC or central line, and Nigel already has a non-regnerative anaemia associated with his CKD. For that reason, we need to be REALLY careful about how much blood we collect from him - pulling the minimum needed for the necessary tests.
Stress and Feline-Friendly Considerations
We know cats generally tend to cope less well with environmental changes than dogs do, and admission to the clinic presents any patient with a whole host of unfamiliar sights, sounds, and smells - not to mention us regularly examining, poking and prodding them (often with needles!).
This is challenging for any patient - but even more so in a cat with lower urinary tract disease. So keeping stress low, and our feline-friendly nursing considerations front-of-mind is really important.
Using gentle handling, distraction with things like lickelix where possible, and finding the approach that works best for the individual patient is key. Nigel is not going to be a candidate for food distraction given that he’s hyporexic - the last thing we want to do is cause food aversion by him associating treats with examination or treatment.
He loves a ‘less is more’ approach, and appreciates a place to hide - so we adapted our handling accordingly, ensuring that he had plenty of hiding places in his kennel should be want some time out.
Long-term care, client education and SC fluids/O tube use
The last thing we’ll look at in his case is a bit of a cheat one… it’s really easy to do client education on long-term care of a CKD cat when your client is an internal medicine nurse, after all!
BUT in the majority of cases we see, that’s not the case. And you still have a patient with CKD, needing things like dietary changes, medications, subcutaneous fluids, and maybe even feeding tube use at home.
Veterinary nurses and technicians are ideally placed to help with this - demonstrating how to give subcutaneous fluids, and how to clean, dress, and use a feeding tube, for example.
There is SO much we can do in the long-term care of patients like Nigel, including:
Educating on why a renal diet is indicated, and advising on how to transition to this (and how much to feed - especially with that weight loss history!)
Regularly seeing them for weight, body and muscle condition score checks
Collecting samples on behalf of the vet, and performing urine analysis as part of renal staging
Measuring blood pressure in a cat-friendly way
Administering medications like erythropoeitin and iron on a regular basis
Providing advice on managing concurrent diseases, especially conditions like arthritis where we’re unlikely to be able to give NSAIDs - remember, CKD is common in senior pets, so we’re likely to see other diseases too!
And lots more.
So there you have it! Nigel and I both hope that his case has helped you think about some of the skills you could use to help your renal patients - and get you doing more at the same time!
If you want more help planning care for your renal patients, I actually have a guide you can check out on how to do that here.
What else would you add into Nigel’s nursing care plan? Was there anything on your list I missed? DM me on Instagram and let me know!
